Intimidation: Practitioners speak up about this unresolved problem (Part I)

From the March 11, 2004 issue

All too often, seasoned healthcare providers feel compelled
to warn new staff members about a particularly difficult physician,
and perhaps even shield them from this person for as long
as possible. It's a telling sign of a culture that tolerates,
even fosters, intimidation. More than 2,000 (N=2,095) healthcare
providers from hospitals (1,565 nurses, 354 pharmacists, 176
others) responded to our November 13, 2003, survey on this
subject. Sadly, they clearly confirmed that intimidating behaviors
continue to be far from isolated events in healthcare. What's
more, these behaviors are not necessarily limited to a few
difficult physicians, or for that matter, to physicians alone.
In Part I of our report, learn what respondents had to say
about workplace intimidation. Recommendations to address this
longstanding problem will be presented in Part II of our report,
in the March 25, 2004, edition of the newsletter.

Healthcare providers feel the sting of intimidating
behaviors. Regardless of the source of intimidation
(physicians or others), respondents reported that subtle
yet effective forms of intimidation occurred with greater
frequency than more explicit forms. For example, during
the past year, 88% of respondents encountered condescending
language or voice intonation (21% often); 87% encountered
impatience with questions (19% often); and 79% encountered
a reluctance or refusal to answer questions or phone calls
(14% often). Almost half of the respondents reported more
explicit forms of intimidation during the past year, such
as being subjected to strong verbal abuse (48%) or threatening
body language (43%). Incredibly, 4% of respondents even
reported physical abuse.

Physicians clearly intimidate, but it's not just physicians. According to respondents, physicians and other prescribers
engaged in intimidating behaviors more frequently than other
healthcare providers (e.g., pharmacists, nurses, supervisors).
For example, respondents reported that physicians/prescribers
often used condescending language, were reluctant to answer
questions or return phone calls, and were impatient with
questions at least twice as often as other healthcare providers.
Sixty-nine percent of respondents told us that physicians/prescribers
had often (12%), or at some time during the past year (57%),
stated: "Just give what I ordered;" whereas 34%
of respondents encountered similar pressure from other healthcare
providers to give what the prescriber had ordered. Likewise,
physicians and prescribers more frequently exhibited strong
verbal abuse and threatening body language than other healthcare
providers.

On the other hand, about 40% of respondents reported that
both physicians/ prescribers and other healthcare providers
had reported (or threatened to report) them to their manager
during the past year. In fact, respondents made it abundantly
clear that intimidating behaviors were not attributable
to physicians/prescribers alone; they encountered a surprising
degree of intimidation among other healthcare providers
as well. Furthermore, repeated occurrences of intimidating
behavior did not arise from a single menacing individual.
Thirty-eight percent reported that 3-5 individuals were
involved, and 19% reported repeat occurrences with more
than 5 individuals during the past year. These disturbing
findings suggest that healthcare providers at large, not
just 1-2 difficult physicians, have adopted this unhealthy
and unsafe practice habit.

Intimidation clearly impacts patient safety. Almost
half (49%) of all respondents told us that their past experiences
with intimidation had altered the way they handle order
clarifications or questions about medication orders. At
least once during the past year, about 40% of respondents
who had concerns about a medication order assumed that it
was correct, or asked another professional to talk to the
prescriber, rather than interact with the particularly intimidating
prescriber. Three quarters (75%) had asked colleagues to
help them interpret an order or validate its safety so that
they did not have to interact with an intimidating prescriber.
Similarly, 34% reported that they found the prescriber's
stellar reputation intimidating and had not questioned an
order for which they had concerns. Even when the prescriber
had been questioned about the safety of an order, 31% of
respondents had suggested or allowed the physician to give
the medication himself, and almost half (49%) felt pressured
to accept the order, dispense a product, or administer a
medication despite their concerns. As a result, 7% of respondents
reported that they had been involved in a medication error
during the past year in which intimidation clearly played
a role.

Respondents not satisfied with efforts to reduce intimidation.
Only 60% of respondents felt their organization had clearly
defined an effective process for handling disagreements
with the safety of an order. Even less, just 33%, felt that
the process allowed them to bypass a particularly intimidating
prescriber, or their own supervisor if necessary. While
70% of respondents reported that their organization/manager
would support them if they reported intimidating behavior,
in the end, only 39% felt that their organization dealt
effectively with intimidating behavior.

Gender makes little difference. Female respondents
(86%) to the survey outnumbered male respondents (14%),
but only minor differences were reported in the frequency
with which each group encountered intimidating behaviors.
Overall, male respondents reported a higher degree of effects
from intimidation, but again, the differences were not large.
For example, more male respondents reported that they had,
during the past year, assumed that a medication order was
correct and safe rather than interact with a particular
prescriber (48% male, 37% female); assumed that a medication
order was correct and safe because of the stellar reputation
of the prescriber (42% male, 32% female); and felt pressure
to accept an order, dispense a product, or administer a
drug despite concerns about its safety (53% male, 49% female).
On the other hand, female respondents had asked another
professional to talk to a particularly intimidating person
more often than male respondents (41% female, 35% male).

The least experienced practitioners may not be the most
affected. Surprisingly, nurses with less than 2 years
experience encountered intimidating behaviors from both
physicians/prescribers and others less frequently than more
experienced nurses. Nurses with less than 2 years experience
also reported fewer individuals involved in repeated encounters,
but the number steadily rose as nurses gained more experience.
Furthermore, nurses with less than 2 years experience reported
less frequent effects from workplace intimidation than nurses
with more experience, with one notable exception: newer
nurses had asked another professional to talk to a particularly
intimidating person more often than experienced nurses.
These findings suggest that perhaps less experienced nurses
are initially shielded from intimidating staff, or they
are not confident enough to speak up about drug safety issues,
thus encountering less frequent situations where intimidation
may be a factor. It's also possible that less experienced
nurses were not as comfortable as more experienced nurses
in disclosing intimidation and its effects on their practice.
To this point, there was a significantly lower response
rate to the survey from nurses with less than 2 years experience
(n= 63, 4% of nurse respondents).

Nurses with 2-5 years experience reported a marked increase
in the frequency with which they encountered intimidating
behaviors, and were more negatively affected by these behaviors
when compared to nurses with less than 2 years experience.
For example, 40% of nurses with less than 2 years practice
reported that their past experiences with intimidation had
altered the way they handle order clarifications; the same
was true for 54% of nurses with 2-5 years experience. Similar
effects of intimidation continued for nurses with more than
5, even 10, years experience. However, as years of experience
increased, nurses reported less satisfaction with the organization's
ability to handle intimidation effectively (48% satisfied
during the first 2 years, 33% satisfied by years 5-10),
with some improvement after 10 years (39% satisfied).

Pharmacists reported a remarkably similar pattern of experiences
associated with the number of years in practice, although
it was less pronounced. Overall, pharmacists with less than
2 years experience reported fewer intimidating behaviors
than pharmacists with more experience. They also reported
fewer individuals involved in repeated encounters involving
intimidation, but the number steadily rose as pharmacists
gained more experience, and then decreased after 10 years
of practice. Likewise, the negative effects from intimidating
behaviors were fewer for pharmacists with less than 2 years
experience than for those with more experience. In this
survey, 50% of pharmacists with less than 2 years of practice
reported that their past experiences with intimidation had
altered the way they handle order clarifications; the same
was true for 60% of pharmacists with 2-5 years experience.
But as with inexperienced nurses, pharmacists with less
than 2 years practice comprised a small percent (7%, n=24)
of all pharmacists who responded to the survey. Also like
nurses, pharmacists' satisfaction with the organization's
ability to handle intimidation effectively decreased along
with their years of service (46% satisfied during the first
2 years, 22% satisfied by years 5-10), with some improvement
after 10 years (38% satisfied).

Intimidation may affect pharmacists more than nurses.
Overall, pharmacists and nurses encountered about the same
frequency of intimidating behaviors by physicians/prescribers.
However, pharmacists encountered less frequent use of condescending
language or threatening body language. On the other hand,
pharmacists reported more frequent intimidating behaviors
perpetuated by other healthcare providers, especially strong
verbal abuse (encountered by 50% of pharmacists, 38% of
nurses), and a reluctance or refusal to answer questions
or return calls (encountered by 83% of pharmacists, 69%
of nurses). Because a pharmacist may interact with a larger
scope of prescribers and other providers than a nurse, it's
not surprising that 30% of pharmacists reported that more
than 5 individuals were involved in repeated occurrences
of intimidating behavior; only 17% of nurses reported this.

Pharmacists also reported more frequent effects from intimidation
than nurses. For example, 64% of pharmacists and 34% of
nurses reported that, during the past year, they had assumed
a medication order was correct and safe rather than interact
with a particular prescriber. Pharmacists (56%) reported
more often than nurses (29%) that they had assumed a medication
order was correct because of the stellar reputation of the
prescriber. Pharmacists (49%) had also asked another professional
to talk to an intimidating prescriber about an order more
frequently than nurses (38%). While more nurses (62%) than
pharmacists (50%) felt that their organizations had defined
an effective process for handling disagreements with the
safety of an order, both reported equal dissatisfaction
with their organizations' ability to deal effectively with
intimidation (61% dissatisfied). Visit Click here
to view selected data from the survey.

Look for Part II of our report covering suggestions
to reduce workplace intimidation in our next issue.